Letter From The Editor

Bruce D. Cheson, MD

Life, liberty, and the pursuit of health care.

Are these the unalienable rights as put forth by our founding fathers? There seems to be a bit of a rift in our country over that issue. Bricks are being thrown, white powder sent in the mail, Alaskan rifle sights placed on pictures of various (particularly Democratic) congresspersons, threats, racial epitaphs [sic] (as noted on TV by the head of the Republican National Committee, Michael Steele). Truly acts which, were we to see them occur in a foreign land on the evening news, would incur ridicule. The only time I can remember such a national schism was during the Vietnam War, but then peaceful protest was the order of the day, not violence.

This civil unrest is the result of the events leading to the passage of the health care bill. I had originally intended to write about the pros and cons of this historic piece of legislation, but more rational minds had me delete my first draft. I was going to discuss how there would be fewer uninsured, no annual or lifetime limits, and no exclusions for preexisting conditions. I was going to illustrate the impact on the practicing physician, including the 10% increase in Medicare for the primary care practitioner. However, I could not figure out how that increase compensated for the 40% reduction in Medicare reimbursement for procedure-based charges that was implemented on January 1st of this year.

I had intended to write about the anticipated increase in demand from the new wave of insured people and those seeking preventive medicine. However, I have yet to figure out whether the supply will still be there. The reduction in income for practitioners will force some to lay off office personnel and some to refuse Medicare and insurance, whereas others will decide to close their practices. This ripple effect will further worsen an ongoing scenario. The proportion of physicians in small practices dropped from more than two-thirds in 2005 to less than one-half 3 years later, and the slide inexorably continues. Doctors are forced to amalgamate or join hospitals or large practices to survive, becoming salaried employees with incomes substantially lower than they are used to. A lower salary will make it even more difficult to repay medical school loans, which will now be funded by the government! Proponents claim that medical care is better coordinated, with fewer night and weekend calls, shorter working hours, and more time for patient-related and personal activities. Does this really compensate for lost wages? Physicians will supposedly be able to delegate more of the administrative headaches to others, but the effect has not always been favorable. Private physicians argue that the patient-doctor relationship will suffer and refer to the many HMOs under which patients see different physicians each visit.

I was going to speculate on how we were going to pay for this new bill, which is proposed as a cost-saving measure. I am not enthralled with my contribution in the way of a tax increase. Cutting back on wars would surely help! In the New York Times on March 20, a number of physicians were interviewed on the subject. Several of their responses were off the wall, unrealistic, or downright hilarious. One noted that we pay automobile insurance only for major accidents, not for every dent and scratch. Extrapolating to health care, he claimed that the current system rewards people for being sick. His recommendation was to just cover catastrophes. In other words, no cancer screening, no preventive medicine, no vaccinations. To the extreme, no antihypertensive medications, no rituximab maintenance. Another 3 responders wanted to increase integrative medicine, restore humanity to medicine, and counsel nutrition. While I support their causes, I cannot agree with their projection of a sufficient impact on cost.

Those that recommended a focus on reducing doctor overtreating, childhood overeating, and lawyer oversuing have my vote. I would also throw in the smokers who puff away a large portion of our economy.

The problem is that I have no clue about what is actually in that bill. I haven’t read it and assume that few others have. I read the papers and Time magazine, and I listen to the news. Thus, I have been warned not to comment as it is a no-win situation. So, I will keep my opinions to myself until I have a better idea as to what is really going on, as I value my dog and the windows on my house.

I hope there will be additional, peaceful, and rational debate so that whatever our children are eventually saddled with will be something we/they can live with and afford. We also need more education of the consumer. Importantly, it is also time to move on to tackle the other crises facing our nation, so that the star-spangled banner will once again wave o’er the land of the free and the home of the paid.

Until next month…

Bruce D. Cheson, MD